Broadening the Differential: Disclosures Spine and Lower Extremity - - PowerPoint PPT Presentation

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Broadening the Differential: Spine and Lower Extremity Injuries in the Young Athlete

• Dr. Nirav K. Pandya

Assistant Professor of Orthopaedic Surgery Director, Pediatric Sports Medicine UCSF Benioff Children’s Oakland Nirav.Pandya@ucsf.edu

Disclosures

• Consultant - Orthopediatrics
• Committee Member – POSNA

Goals

• Epidemiology
• Global Approach to Pediatric Sports Injuries
• Pediatric Fracture Management
• Top Sports Cases
• Apophysitis (Osgood Schlatter / Sever’s / SLJ)
• Pelvic Avulsion Injuries
• SCFE
• Anterior Knee Pain
• Back Injuries

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Why Are Kids Different?

50% of all pediatric athletes will suffer at least 1 significant injury / year!

Key History Questions

• Insidious and dull vs. sharp and traumatic pain
• Diffuse vs. localized pain
• Pain before / after sports vs. during sport
• Normal gait vs. locking, instability, limping

vs.

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Key History Questions

• Hours / week, miles / week, pitches / week
• Number of teams (club, school)
• Shoewear changes / inserts / braces
• Medications / supplements / alternative tx
• Prior MSK problems
• Family history
• Grades
• Emotional health

Key Physical Exam Maneuvers

Location of palpable pain will direct you to injury 99% of time!!

Imaging ALL PATIENTS SHOULD GET AN AP AND LATERAL X-RAY OF THE AFFECTED JOINT!!!

• Ex. 10 y/o soccer player with 6 weeks of anterior

knee pain

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Osteosarcoma Pediatric Fractures Pediatric Fractures

• The vast majority of pediatric sports

injuries still involve ruling out or treating fractures

• Children can mask fractures very

easily and initial radiographs can be negative

• Do not feel bad immobilizing a child

if you are not sure

• Fractures constitute 10 % - 25 % of all pediatric

injuries

• Risk of fracture from birth to 16 years:
• Boys: 42%
• Girls: 27%

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Why Are Children’s Fractures Different? Why Are Children’s Fractures Different?

• Growth Plate (Physis)
• Periosteum
• Ligaments
• Physiology
• Bone Structure

Bone Anatomy

• Epiphysis
• Metaphysis
• Diaphysis
• Periosteum
• Physis

The Physis: The Difference Maker

• Many childhood fractures involve the physis
• 20% - 25% of all skeletal injuries
• CAN disrupt growth of bone
• Length and /or angulation
• Injury near but not at the physis can stimulate bone

to grow more

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Salter-Harris Classification

• Classification system to

delineate risk of growth disturbance

• Higher grade fractures =

increase risk

• Growth disturbance can

happen with ANY physeal injury

Physeal Injuries: Growth Disturbance

• Fractures with highest rate of growth disturbance:
• Distal femur
• Distal tibia
• Late reduction of distal radius

50%

25% Children vs. Adults

• LIGAMENTS:
• Pediatric ligaments stronger than bone
• More likely to get avulsion than ligament tear

Children vs. Adults

• PHYSIOLOGY:
• More robust blood supply; less chance of non-union
• Children tend to heal fractures faster than adults
• Advantage: shorter immobilization times
• Disadvantage: misaligned fragments become

“solid” sooner

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Remodeling Potential Treatment Principles

1. AP and lateral x-rays of fracture site 2. AP and lateral x-ray of joint above / below 3. Kids can have occult injuries 4. If tender around growth plate, assume Salter Harris I

Treatment Principles

What do you do to treat definitively?

Treatment Principles

Kids don’t get stiff!!!

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Top Cases Case 1: Apophysitis Case 1: Apophysitis

When growing pains are not growing pains

Case 1: Apophysitis

• Apophysis = growth

plate where muscle attaches

• Bone growth >>

muscle growth

• Apophysitis =

irritation of the apophysis due to tight muscles / overuse

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Osgood – Schlatter’s Sinding-Larsen Johansson Syndrome (SLJ) Sever’s Ischial Tuberosity Apophysitis

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Iselin’s Disease

• Between 7 – 12 years of age (sk. immature)
• Sever’s usually younger
• OS / SLJ / IT / Iselin’s usually older
• Soccer and basketball!!
• Overuse, overuse, overuse
• Growth spurt, growth spurt, growth spurt
• Pain over bone prominences NOT tendon

Key H+ P Osgood - Schlatter Sever’s

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Osgood - Schlatter / Sever’s : Key H+ P

During growth spurt, bones grow faster than muscle > more tense muscles > more pull on apophysis

• R.I.C.E
• Avoid excessive running
• Stretching / PT
• Orthosis for flat feet
• Patellar tendon straps

Osgood - Schlatter Treatment

• R.I.C.E
• Avoid excessive running
• Stretching / PT
• Heel cups
• Minimize cleat wear

Sever’s Treatment What To Worry About

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Return to Play Case 2: Pelvic Avulsion Fractures Bony Injuries – Avulsion Fx’s Pelvic Anatomy

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Pelvic Anatomy

• Avulsion Fractures
• Ages 14 - 25
• “I heard a pop”
• Sprinters, jumpers, hurdlers, soccer, football
• Sudden violent muscle contraction
• Separation in cartilaginous area between apophysis

and bone

Bony Injuries – Avulsion Fx’s

Bony Injuries – Avulsion Fx’s

Prompt diagnosis to avoid chronic pain

Bony Injuries – Avulsion Fx’s

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Prompt diagnosis to avoid chronic pain

Bony Injuries – Avulsion Fx’s

• Treatment
• Rest and ice
• Protected weight bearing until pain free
• Progression to light isometric stretching and full

weight bearing

• Return to full sports once full strength and pain-

free range of motion is achieved

Bony Injuries – Avulsion Fx’s

Case 3: Slipped Capital Femoral Epiphysis (SCFE) Slipped Capital Femoral Epiphysis (SCFE)

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SCFE – Epidemiology

• Common problem with

serious consequences

• Annual incidence - 2 to 13

per 100,000

• Increased risk in certain

groups

• Male
• Obese
• Peripubertal
• Polynesian

SCFE – Etiology

• Mechanical insufficiency of the proximal femoral

physis to resist the load across it due to:

• Endocrine factors
• Previous radiation therapy
• Renal osteodystrophy
• Obesity

SCFE – Etiology

• Mechanical insufficiency of the proximal femoral

physis to resist the load across it due to:

• Decreased femoral anteversion
• Decreased neck-shaft angle
• Deeper acetabulum
• Acetabular retroversion

Pathoanatomy

• Proximal femoral metaphysis impinges

against acetabulum

• Cartilage + labral damage
• Posteromedial callus also develops over time
• Long term risk of FAI and DJD

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Pathoanatomy

Why do we care?

AVN and DJD

Presentation and Workup

• Complaints of groin or thigh pain + / - trauma
• May or may not be ambulating
• May complain of knee pain!!
• AP and frog pelvis x-ray
• MRI of hip if not sure

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Classification

• Functional
• Stable: able to bear weight
• Unstable: unable to bear weight

AVN risk in unstable slips can range from 10% to 60%, and is higher in younger patients with a shorter duration of preceding symptoms

Radiographs Initial Treatment

• Prevent further slip progression
• Restore proximal femoral anatomy

Wheelchair and ED

Goals of Treatment

• Prevent further slip progression
• Restore proximal femoral anatomy

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Treatment Options Return to Activity??

• 1. Wheelchair / crutches until 6 weeks post-op
• 2. Full-weightbearing @ post-op week 6
• 3. Return to sports at 3 months post-op
• 4. X-Rays every 6 months until 2 years post-op
• 5. Watch out for FAI

Case 4: Anterior Knee Pain

Irritation Behind Patella

What is PF Syndrome?

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Patellofemoral Syndrome: Key H + P

• No trauma
• Dull pain around knee cap or “deep inside”
• “Feels like sandpaper underneath kneecap”
• Playing sports all the time
• Stairs and sitting for long time = pain
• Benign exam
• Lack flexibility and core strength

Patellofemoral Syndrome

Assess Single Leg Squat Assess Popliteal Angles

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Core Stability Imaging

• AP, lateral, notch, and merchant x-rays (r/o OCD, fractures, etc)
• MRI only if does not improve with 6 – 12 weeks of PT

Patellofemoral Pain Syndrome

• Treatment
• Rest
• Pharmacologic
• NSAID’S
• PT
• Core / Hip Strengthening
• Stretching
• Orthosis

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Can I Play Through the Pain?

• Consequences of Playing:
• No structural damage but pain

will last longer

• Minor risk of structural damage
• Major risk of structural damage

Surgery: Is It Ever Indicated? Case 5: Back Pain Back Pain in Pediatrics

• Uncommon CC, but common occurrence
• 7% of 12yo with >1 episode LBP
• 50% of 18yo F, 50% of 20yo M
• Most not definitively diagnosed
• Most benign etiologies
• ~Half of episodes musculoskeletal (ER)
• Remember, backpacks <15-20% of weight!

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Back Pain in Pediatrics: Differential Diagnosis

Red Flags!

• Infectious, Neoplastic, Rheumatologic
• Acute trauma
• Night pain
• Worsening pain
• Systemic symptoms
• Neuro symptoms
• Hx CA/TB exposure
• Severe disability
• Young age (<4yo)
• Bowel / bladder

Spondylolysis Spondylolysis

• Spondylolysis: Defect (separation) in pars

interarticularis

• Spondylolisthesis: Anterior slippage of vertebral

body over next lowest body

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Who Is At Risk?

• Athletes with repetitive

hyperextension

• Gymnasts
• Divers
• Football offensive linemen
• Pole vaulters
• Weight lifters
• Wrestlers
• LAXers!

Spondylolysis: H and P

• Low back pain without radiation
• Insidious onset
• Worse with activity
• Rarely radiating
• Usually no hx trauma
• Usually no neuro deficits

Spondylolysis: H and P

• Pain with hyperextension
• +/- “Step-off” at L5
• +/- Facet joint tenderness
• Hamstring spasm – classic in adolescents!
• Phalen-Dickson sign
• hip-flexed, knee-flexed gait

Radiographs: Scottie Dog

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Radiographs: Scottie Dog

If not sure, then order CT, MRI, etc

Treatment

• Depends on SLIPPAGE and SYMPTOMS and

SKELETAL MATURITY

• Activity restriction
• NSAIDs
• Physical therapy
• Abdominal/back strengthening
• Hamstring stretching
• Bracing/Casting
• Symptomatic / Acute pars fx
• Surgery

Pediatric Sports Top 10 List

• 1. Pediatric sports injuries are at an epidemic level
• 2. Kids have hard time verbalizing and have multiple pressures
• 3. Location of palpable pain will lead you to injury 99.0% of time
• 4. Pediatric fractures are most common sports injuries
• 5. Kids don’t get stiff and heal faster; watch out for growth issues
• 6. Bony tenderness in athlete = apophysitis
• 7. Pop and pelvic pain = avulsion fracture
• 8. Thigh pain = rule out SCFE
• 9. Look at mechanics and core strength for anterior knee pain

10.Pain with hyperextension = spondy

Thank You